Appendix C – Recognising Abuse

Signs, indicators and types of abuse in Children and Adults

It is important to remember that many children and adults will exhibit some of these signs and indicators at some time, and the presence of one or more should not be taken as proof that abuse is occurring. There may well be other reasons for changes in behaviour such as death, or the birth of a new baby in the family, relationship problems between parents/carers etc. However, you should always report anything that causes you to suspect that abuse may be happening in order for appropriate action to be taken to ensure the welfare and safety of children and adults.

Within the relevant legislation and statutory guidance there are four known categories of abuse identified for children and ten categories of abuse noted for adults.

Children and Adults Physical, emotional (or psychological), sexual and neglect.

Adults Physical, emotional (or psychological), sexual, financial, discriminatory, institutional, domestic abuse, modern slavery, neglect and acts of omission and self neglect.

Please note that the tabled examples and signs detailed below may also be indicators of other medical factors and may not necessarily confirm abuse and neglect. These tables are provided as a guide to help with the assessment process and the work with children, adults and their families.

PHYSICAL ABUSE

Examples include Signs include  Shaking  Unexplained bruising, marks or  Pinching injuries on any part of the body  Slapping  Frequent visits to the GP or A&E  Force-feeding  An injury inconsistent with the  Biting explanation offered  Burning or Scalding.  Fear of parents or carers being  Causing needless physical approached for an explanation discomfort  Aggressive behaviour or severe  Inappropriate restraint temper outbursts  Locking someone in a room  Flinching when approached  Reluctance to get changed or wearing long sleeves in hot weather  Depression  Withdrawn behaviour or other behaviour change  Running away from home/ residential care  Distrust of adults, particularly those with whom a close relationship would normally be expected

EMOTIONAL/PSYCHOLOGICAL ABUSE

Examples include Signs include  Intimidation and/or threats  A failure to thrive or grow  Bullying  Sudden speech disorders  Rejection  Developmental delay, either in terms  Shouting of physical or emotional progress  Indifference and the withdrawal of  Behaviour change approval  Being unable to play or socialise with  Denial of choice others  Deprivation of dignity or privacy  Fear of making mistakes  The denial of human and civil rights  Self harm  Harassment  Fear of parent or carer being  Being made to fear for one’s well approached regarding their being behaviour  Confusion

SEXUAL ABUSE

Examples include Signs include  Rape and other sexual offences  Pain or itching in the genital/anal  For adults, sexual activity including areas sexual contact and non-sexual  Bruising or bleeding near genital/anal areas contact that the person does not  Sexually transmitted disease want, to which they have not  Vaginal discharge or infection consented, could not consent, or  Stomach pains were pressured into consenting to.  Discomfort when walking or sitting  Being encouraged or enticed to touch down the abuser  Pregnancy  Coercing the victim into watching or  Sudden or unexplained changes in participating in pornographic videos, behaviour, e.g. becoming aggressive photographs, or internet images or withdrawn  Fear of being left with a specific  Any sexual relationship that develops person or group of people where one is in a position of trust,  Nightmares power or authority  Leaving home  Sexual knowledge which is beyond their age or development age  Sexual drawings or language  Bedwetting  Saying they have secrets they cannot tell anyone about  Self harm or mutilation, sometimes leading to suicide attempts  Eating problems such as overeating or anorexia

NEGLECT

Examples include Signs include  Withholding help or support  Constant hunger, sometimes necessary to carry out daily living stealing food from others tasks  Dirty or ‘smelly’  Loss of weight, or being constantly  Ignoring medical and physical care underweight needs  Inappropriate dress for the weather  Failing to provide access to health,  Complaining of being tired all the social or educational support time  The withholding of medication,  Not requesting medical assistance nutrition and heating and/or failing to attend appointments  Having few friends  Keeping someone in isolation.  Worsening of health conditions  Failure to intervene in situations that  Pressure sores are dangerous to the person  Mentioning their being left alone or  Inadequate supervision and guidance unsupervised – leaving the child to cope alone,  Sore or extreme nappy rash abandoning them or leaving them  Skin infections with inappropriate carers and failing  Lack of response to stimuli or to provide appropriate boundaries contact about behaviours such as under age  Poor skin condition(s)  Frozen watchfulness sex or alcohol.  Anxiety

 Distressed

 Child moves away from parent under

stress

 Little or no distress when separated from primary carer  Inappropriate emotional responses  Language delay Self –Neglect (Adults)

Can sometimes be as a result of a person’s choice of lifestyle and covers a wide range of behaviour including: Examples include Signs include  Little or no personal care  poor grooming, dirty or ragged  Refusing medication or refusing to clothes, unclean skin and fingernails stay on medication  unwilling to accept medical care  unable to focus, carry on normal  Disorientated or incoherent conversation or answer basic  Unsafe living conditions questions about date, place, and time  Inability to manage finances and  Lack of food or basic utilities in the property home, unclean living quarters,  Isolation rodents or other vermin  Hoarding when it becomes extreme  Hoarding animals or trash, inability to (including animal hoarding). get rid of unneeded items  Inability to manage finances and

property: not paying bills, repeatedly In these circumstances there is no borrows money, gives money or abuser. property away  Little contact with family or friends, no social support  Living in grossly unsanitary conditions  Suffering from untreated illness or disease/condition  Suffering from over or under eating to the extent that if untreated the adult’s physical or mental health could be impaired  Creating a hazardous situation that would likely cause serious physical harm to the adult or cause substantial loss of assets

Adults may experience several other types of abuse as detailed below:

FINANCIAL ABUSE (Adults)

Examples include Signs include  Being over charged for services  Lack of basic requirements e.g.  Being tricked into receiving goods or food, clothes, shelter services that they do not want or  Inability to pay bills. need  Unexplained withdrawals from  Inappropriate use, exploitation, or accounts. misappropriation of property and/or  Inconsistency between standard of utilities living and income  Theft  Reluctance to take up assistance  Deception which is needed  Fraud  Unusual interest by family and other people in the person’s assets  Exploitation or pressure in  Recent changes in deeds connection with wills  Power of Attorney obtained when person lacks capacity to make the decision.

DISCRIMINATORY

Examples Signs  Use of inappropriate “nick names”  Being treated unequally from other  Use derogatory language or users in terms of the provision of terminology care, treatment or services  Enforcing rules or procedures which  Being isolated undermine the individual’s well being  Derogatory language and attitude by  Denial to follow one’s religion carers  Lack of appropriate food  Dismissive language by staff  Denial of opportunity to develop  Hate campaigns by neighbours or relationships others  Denial of health care.  Deteriorating health  Indicators of other forms of abuse

ORGANISATIONAL ABUSE

Examples Signs  Service users required to ‘fit in’  Inflexible daily routines, for example: excessively to the routine of the set bedtimes and/or deliberate service waking  More than one individual is being  Dirty clothing and bed linen neglected  Lack of personal clothing and  Everyone is treated in the same way possessions  Other forms of abuse on an  Inappropriate use of nursing and institutional scale medical procedures  Lack of individualised care plans and failure to comply with care plans  Inappropriate use of power, control, restriction or confinement  Failure to access health care, dentistry services etc  Inappropriate use of medication.  Misuse of residents’ finances or communal finances  Dangerous moving and handling practices  Failure to record incidents or concerns

Other types of abuse Staff should also have an awareness of the following other types of abuse:

Domestic Violence and Abuse As of 1st March 2013, the Home Office definition of Domestic violence and abuse is:

Any incident or pattern of incidents of controlling1, coercive2 or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass but is not limited to the following types of abuse; psychological, physical, sexual, financial and/or emotional Source: www.homeoffice.gov.uk

In all cases where there is knowledge or suspicion that there exists a potential for a child or children to be suffering harm as a result of domestic violence and abuse, then a referral should be made to Children’s Social Care via the First Response Team (FRT) who act as the first point of contact for all referrals in relation to cases that meet the threshold for significant harm- for further information please refer Section 1E threshold framework ‘ Accessing the right help at the right time’. www.staffsscb.org.uk and speak with the Designated Safeguarding Officer.

Where it is thought that a victim of domestic violence and abuse meets the definition of a Adult at Risk, then an Adult Protection referral should be made to the Contact Centre on 0345 604 2719.

Hidden Harm

Children may be suffering from the effects of what is known as ‘hidden harm’ if they live with parents or carers who are misusing drugs or alcohol. Children in these situations may be acting as young carers or they may be subjected to any of the forms of abuse described above. Separate policies and procedures for children living with parents who misuse substances and those who are deemed as young carers can be found on the SSCB website. www.staffsscb.org.uk/Professionals/Procedures/Procedures.aspx

Child Sexual Exploitation

Child Sexual exploitation (CSE) is a form of sexual abuse. It occurs where an individual or group takes advantage of an imbalance of power to coerce, manipulate or deceive a child or young person under the age of 18 into sexual activity (a) in exchange for something the victim needs or wants, and/or (b) for the financial advantage or increased status of the perpetrator or facilitator. The victim may have been sexually exploited even if the sexual activity appears consensual. Child sexual exploitation

1 Controlling behaviour is: a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour.

2 Coercive behaviour is: an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim. does not always involve physical contact; it can also occur through the use of technology. (DFE2017)

Children and Young people do not make informed choices to enter or remain in sexual exploitation. Rather, they do so from coercion, enticement, manipulation, fear or desperation. For further guidance www.staffsscb.org.uk/Professionals/Procedures/Procedures.aspx

Forced Marriage Forced marriage3 is a marriage without the full and free consent of both parties. It is a form of domestic violence and an abuse of human rights. In an arranged marriage the family will take the lead in arranging the match but the couples have a choice as to whether to proceed. In forced marriage, one or both spouses do not (or, in the case of some disabled young people and some vulnerable adults, cannot) consent to the marriage and some element of duress is involved. Duress can include physical, psychological, sexual, financial and emotional pressure.

It is important to note that the Mental Capacity Act does NOT allow for consent to marry to be given on behalf of a person without capacity to make this decision for themselves.

Female Genital Mutilation

Female genital mutilation (FGM) includes procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons.” (World Health Organisation, 2014). It is illegal in the UK. FGM is known by a number of names including „female genital cutting‟, „female circumcision‟ or initiation‟. The term female circumcision suggests that the practice is similar to male circumcision, but it bears no resemblance to male circumcision, has serious health consequences and no medical benefits. FGM is also linked to domestic abuse, particularly in relation to „honour based violence‟. For further guidance http://www.staffsscb.org.uk/Professionals/Procedures/Section-Four/Section-Four- Docs/Section-4M-Female-Genital-Mutilation.pdf

Modern slavery/Trafficking Modern slavery encompasses slavery, human trafficking, forced labour and domestic servitude. Traffickers and slave masters use whatever means they have at their disposal to coerce, deceive and force individuals into a life of abuse, servitude and inhumane treatment.

3 Research carried out by the then Department for Children, Schools and Families estimated that the national prevalence of reported cases of forced marriage in England was between 5,000 and 8,000, with the youngest victim being 2 years old and the oldest 76 years.. The organised crime of human trafficking into the UK has become an issue of considerable concern to all professionals with responsibility for the care and protection of children and adults. Any form of trafficking humans is an abuse.

Trafficking of persons means the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat of, or use of coercion, abduction, fraud, deception, abuse of power or of a position of vulnerability. It also includes the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation.

It is important to note that some cases involve UK-born people being trafficked within the UK, e.g. people being trafficked from one town to another. The consent of the victim of trafficking is irrelevant where any of the above methods have been used.

Trafficked people may be used for sexual exploitation, agricultural labour including tending plants in illegal cannabis farms and benefit fraud. Children as well as adults are trafficked.

If you have a concern regarding the possible trafficking of a person you should immediately contact the Designated Officer or make a referral direct to the appropriate team. Practitioners should not do anything which would heighten the risk of harm or abduction to the child or adult.

Race and Racism People from black and minority groups (and their parents or carers) are potentially likely to have experienced harassment, racial discrimination and institutional racism. Although racism causes significant harm it is not, in itself, a category of abuse (unless the victim meets the definition of a vulnerable adult, in which case an appropriate referral should be made) and dealing with it is considered under other specific policies of the Council and the Community Safety Partnership.

Hate Crime The Association of Chief Police Officers (ACPO) and the Crown Prosecution Service (CPS) have a nationally agreed definition of Hate Crime. Hate crimes are taken to mean any crime where the perpetrator's hostility or prejudice against an identifiable group of people is a factor in determining who is victimised. This is a broad and inclusive definition. A victim does not have to be a member of the group. In fact, anyone could be a victim of a hate crime.

The Crown Prosecution Service (CPS) and The Association of Chief Police Officers (ACPO) have agreed 5 monitored strands of hate crime as set out below.

A hate crime is any criminal offence that is motivated by hostility or prejudice based upon the victim's:

 disability  race  religion or belief  sexual orientation  transgender identity Hate crime can take many forms including:

 physical attacks such as physical assault, damage to property, offensive graffiti and arson  threat of attack including offensive letters, abusive or obscene telephone calls, groups hanging around to intimidate, and unfounded, malicious complaints  verbal abuse, insults or harassment - taunting, offensive leaflets and posters, abusive gestures, dumping of rubbish outside homes or through letterboxes, and bullying at school or in the workplace.

If the victim of a Hate Crime meets the definition of an Adult at Risk of abuse and neglect, an Adult Protection referral should be made to the Contact Centre on 0345 604 2719.

Safeguarding People who are vulnerable to being drawn into Violent Extremism and / or Terrorism The current threat from terrorism in the United Kingdom can involve the exploitation of vulnerable people, including children of all ages, young people and adults to involve them in terrorism or activity in support of terrorism.

Violent Extremism is defined by the Crown Prosecution Service (CPS) as:

"The demonstration of unacceptable behaviour by using any means or medium to express views, which:  Encourage, justify or glorify terrorist violence in furtherance of particular beliefs;  Seek to provoke others to terrorist acts;  Encourage other serious criminal activity or seek to provoke others to serious criminal acts;  Foster hatred which might lead to inter-community violence in the UK."

There are a number of offences that can be considered when dealing with violent extremism. They include offences arising through spoken words, creation of tapes and videos of speeches, internet entries, chanting, banners and written notes and publications.

The main offences employed to date have been soliciting murder and inciting racial hatred.

The Stoke-on-Trent and Staffordshire Local Safeguarding Children Boards and the Staffordshire and Stoke-on-Trent Adult Safeguarding Partnership Board recognise the need to protect people against the messages of all violent extremism including that linked to Far Right / Neo Nazi / White Supremacist, Al Qaeda ideologies, Irish Nationalist and Loyalist paramilitary groups, and that linked to Animal Rights movements.

For further guidance http://www.staffsscb.org.uk/Professionals/Procedures/Section- Six/Section-Six-Docs/Section-6L-Staffordshire-and-Stoke-on-Trent-LSCB-and- SSASPB-Prevent-Channel-Guidance.docx Risks that increase the likelihood of abuse happening

There are certain situations and factors that put people at particular risk of abuse. If one or more of these factors are present, it does not mean that abuse will occur but it will increase the risk:

 Isolation  Living in the same household as an abuser  A previous history of abuse  The existence of financial problems  A member of the household experiences emotional or social isolation  Inappropriate physical or emotional environment e.g. lack of privacy and/or personal space  Where there has been a change of lifestyle e.g. illness, unemployment or employment  Dependence on others for personal and practical care  Where a person is dependent on other people to administer money or where several people manage their money  Where the vulnerable person exhibits difficult and challenging behaviour  The carer has difficulties such as debt, alcohol or mental health problems  Poor leadership in care services  Unmonitored provision of care e.g. where reviews or inspections do not take place  Failure to comply with standard operating policies and procedures

Increased Risk to Vulnerable Children

There are many issues that may contribute to child abuse, but some factors increase the risk to children and make them more vulnerable to abuse. They can be found in the background of parents, in the environmental situation and in attributes of the child themselves.

Parental factors:

 Parent has a mental illness  Parent is misusing drugs or alcohol  Parent has already abused a child  Parent has previously had children removed  Unwanted pregnancy/terminations  Parent has a background of abuse when growing up  Parents have unrealistic expectations of the child and lack parenting knowledge  Parent is isolated and has little support  Parent has a learning difficulty/disability

Environmental factors:

 Overcrowding in the house  Poverty or lack of opportunity to improve the family’s resources  Domestic abuse is present  A non-biological adult (i.e. unrelated) living in the house  Family is experiencing multiple stresses

Child factors:

 Baby is sickly, colicky or unwanted  Child has a physical or learning disability  Lack of attachment between child and parent  Child resides in care, particularly residential  Child is excluded from mainstream school  Child uses drugs/alcohol  Child goes missing  Child is living in private fostering arrangements

It is possible to limit the situations where the abuse of children and adults at risk may occur, by promoting good practice to all staff and elected members. Appendix E contains the good practice guidance for staff, elected members and volunteers.